Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline

Hemilaminectomy for thoracolumbar Hansen Type I intervertebral disk disease in ambulatory dogs with or without neurologic deficits: 39 cases (2008-2010)

OBJECTIVE

To describe prognostic factors, outcome, and time to recovery among ambulatory dogs having hemilaminectomy for Hansen Type I intervertebral disk disease.

STUDY DESIGN

Retrospective case series.

ANIMALS

Dogs (n = 38; 39 hemilaminectomies).

METHODS

Medical records (January 2008-May 2010) on all dogs that had hemilaminectomy for Hansen Type I intervertebral disk disease were reviewed. Records for dogs that were ambulatory preoperatively were analyzed for signalment, duration and severity of signs, presence of neurologic deficits, and postoperative outcome. Dogs were categorized based on Frankel score and subcategorized by their level of conscious proprioceptive (CP) deficit. Postoperatively, time to ambulation and to regain normal CP responses was recorded. Results for each group were compared using a χ(2) test and considered significant when P < .05. Recovery times were analyzed using a Cox proportional hazards model.

RESULTS

Seven dogs were categorized as modified Frankel grade I preoperatively and 32 dogs as grade II with varying levels of deficits (1 of these dogs had previously been operated as grade II and was reoperated again as grade II). Increasing degree of CP deficit preoperatively was significantly correlated with longer time to ambulation (P = .005) as well as longer time to CP normal (P = .01). Duration of signs was not significantly correlated with time to ambulation or neurologic recovery for either grade I or II dogs.

CONCLUSIONS

Most dogs recovered well with surgical decompression. Increasing degree of deficits preoperatively is significantly correlated with longer recovery time.

Degenerative lumbar spinal stenosis in older people: current treatment options

BACKGROUND

Degenerative lumbar spinal stenosis is increasingly being diagnosed in persons over age 65. In 2011, 55 793 older people with this condition were treated as inpatients in German hospitals. Among physicians, there is much uncertainty about the appropriate treatment strategy.

METHOD

Selective literature review.

RESULTS

Lumbar spinal stenosis in older people is characterized by spinal claudication and neurological deficits. A precise clinical history and physical examination and ancillary radiological studies are the necessary prerequisites for treatment. Magnetic resonance imaging is the radiological study of choice. Conservative treatment consists of physiotherapy, drugs, and local injections; various surgical treatments can be considered, depending on the severity of the problem. The main purpose of surgery is to decompress the spinal canal. If the lumbar spine is demonstrably unstable, an instrumented fusion should be performed in addition. There is, however, only moderately good evidence supporting the superiority of surgery over conservative treatment. In a prospective study, the complication rate of purely decompressive surgery was found to be 18%. The utility of the current operative techniques cannot be definitively assessed, because they are applied to a wide variety of patients in different stages of the disease and at different degrees of severity, and the reported results are thus not comparable from one trial to another.

CONCLUSION

No evidence-based recommendation on the diagnosis and treatment of lumbar spinal stenosis in older people can be formulated at present because of the lack of pertinent randomized trials.

Nonoperative treatment for lumbar spinal stenosis with neurogenic claudication

BACKGROUND

Lumbar spinal stenosis with neurogenic claudication is one of the most commonly diagnosed and treated pathological spinal conditions. It frequently afflicts the elderly population.

OBJECTIVES

To systematically review the evidence for the effectiveness of nonoperative treatment of lumbar spinal stenosis with neurogenic claudication.

SEARCH METHODS

CENTRAL, MEDLINE, CINAHL, and Index to Chiropractic Literature (ICL) databases were searched up to June 2012.

SELECTION CRITERIA

Randomized controlled trials published in English, in which at least one arm provided data on nonoperative treatments

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration. Risk of bias in each study was independently assessed by two review authors using the 12 criteria recommended by the Cochrane Back Review Group (Furlan 2009). Dichotomous outcomes were expressed as relative risk, continuous outcomes as mean difference or standardized mean difference; uncertainty was expressed with 95% confidence intervals. If possible a meta-analysis was performed, otherwise results were described qualitatively. GRADE was used to assess the quality of the evidence.

MAIN RESULTS

From the 8635 citations screened, 56 full-text articles were assessed and 21 trials (1851 participants) were included. There was very low-quality evidence from six trials that calcitonin is no better than placebo or paracetamol, regardless of mode of administration or outcome assessed. From single small trials, there was low-quality evidence for prostaglandins, and very low-quality evidence for gabapentin or methylcobalamin that they improved walking distance. There was very low-quality evidence from a single trial that epidural steroid injections improved pain, function, and quality of life, up to two weeks, compared with home exercise or inpatient physical therapy. There was low-quality evidence from a single trial that exercise is of short-term benefit for leg pain and function compared with no treatment. There was low and very low-quality evidence from six trials that multimodal nonoperative treatment is less effective than indirect or direct surgical decompression with or without fusion. A meta-analysis of two trials comparing direct decompression with or without fusion to multimodal nonoperative care found no significant difference in function at six months (mean difference (MD) -3.66, 95% CI -10.12 to 2.80) and one year (MD -6.18, 95% CI -15.03 to 2.66), but at 24 months a significant difference was found favouring decompression (MD -4.43, 95% CI -7.91 to -0.96).

AUTHORS' CONCLUSIONS

Moderate and high-quality evidence for nonoperative treatment is lacking and thus prohibits recommendations for guiding clinical practice. Given the expected exponential rise in the prevalence of lumbar spinal stenosis with neurogenic claudication, large high-quality trials are urgently needed.

Five-year follow-up of total disc replacement compared to fusion: a randomized controlled trial

PURPOSE

To evaluate long-term clinical results of lumbar total disc replacement (TDR) compared with posterior lumbar fusion.

METHODS

This prospective randomized controlled trial comprised 152 patients; 80 were randomized to TDR and 72 to fusion. All patients had chronic low back pain (CLBP) and had not responded to nonsurgical treatment. Primary outcome measure was global assessment of back pain (GA), secondary outcome measures were back and leg pain, Oswestry Disability Index (ODI), EQ5D, and SF-36. All measures were collected from SweSpine (Swedish national register for spinal surgery) at 1, 2, and 5 years. Follow-up rate at 5 years was 99.3 %.

RESULTS

Both groups showed clinical improvement at 5-year follow-up. For GA, 38 % (30/80) in the TDR group were totally pain free vs. 15 % (11/71) in the fusion group (p < 0.003). Back pain and improvement of back pain were better in the TDR group: VAS back pain at 5 years 23 ± 29 vs. 31 ± 27, p = 0.009, and VAS improvement of back pain at 5 years 40 ± 32 vs. 28 ± 32, p = 0.022. ODI and improvement in ODI were also better in the TDR group: ODI at 5 years 17 ± 19 vs. 23 + 17, p = 0.02 and ODI improvement at 5 years 25 ± 18 vs. 18 ± 19 (p = 0.02). There was no difference in complications and reoperations between the two groups.

CONCLUSIONS

Global assessment of low back pain differed between the two surgical groups at all follow-up occasions. Significant differences between groups concerning back pain, pain improvement, and ODI were present at 1 year and disappeared at 2 years, but reappeared at the 5-year follow-up.

Conservative management of recurrent lumbar disk herniation with epidural fibrosis: a case report

OBJECTIVE

A retrospective case report of a 24-year-old man with recurrent lumbar disk herniation and epidural fibrosis is presented. Recurrent lumbar disk herniation and epidural fibrosis are common complications following lumbar diskectomy.

CLINICAL FEATURES

A 24-year-old patient had a history of lumbar diskectomy and new onset of low back pain and radiculopathy. Magnetic resonance imaging revealed recurrent herniation at L5/S1, left nerve root displacement, and epidural fibrosis.

INTERVENTION AND OUTCOMES

The patient received a course of chiropractic care including lumbar spinal manipulation and rehabilitation exercises with documented subjective and objective functional and symptomatic improvement.

CONCLUSION

This case report describes chiropractic management including spinal manipulative therapy and rehabilitation exercises and subsequent objective and subjective functional and symptomatic improvement.

The evidence on surgical interventions for low back disorders, an overview of systematic reviews

PURPOSE

Many systematic reviews have been published on surgical interventions for low back disorders. The objective of this overview was to evaluate the available evidence from systematic reviews on the effectiveness of surgical interventions for disc herniation, spondylolisthesis, stenosis, and degenerative disc disease (DDD). An earlier version of this review was published in 2006 and since then, many new, better quality reviews have been published.

METHODS

A comprehensive search was performed in the Cochrane database of systematic reviews (CDSR), database of reviews of effectiveness (DARE) and Pubmed. Two reviewers independently performed the selection of studies, risk of bias assessment, and data extraction. Included are Cochrane reviews and non-Cochrane systematic reviews published in peer-reviewed journals. The following conditions were included: disc herniation, spondylolisthesis, and DDD with or without spinal stenosis. The following comparisons were evaluated: (1) surgery vs. conservative care, and (2) different surgical techniques compared to one another. The methodological quality of the systematic reviews was evaluated using AMSTAR. We report (pooled) analyses from the individual reviews.

RESULTS

Thirteen systematic reviews on surgical interventions for low back disorders were included for disc herniation (n = 6), spondylolisthesis (n = 2), spinal stenosis (n = 4), and DDD (n = 4). Nine (69 %) were of high quality. Five reviews provided a meta-analysis of which two showed a significant difference. For the treatment of spinal stenosis, intervertebral process devices showed more favorable results compared to conservative treatment on the Zurich Claudication Questionnaire [mean difference (MD) 23.2 95 % CI 18.5-27.8]. For degenerative spondylolisthesis, fusion showed more favorable results compared to decompression for a mixed aggregation of clinical outcome measures (RR 1.40 95 % CI 1.04-1.89) and fusion rate favored instrumented fusion over non-instrumented fusion (RR 1.37 95 % CI 1.07-1.75).

CONCLUSIONS

For most of the comparisons, the included reviews were not significant and/or clinically relevant differences between interventions were identified. Although the quality of the reviews was quite acceptable, the quality of the included studies was poor. Future studies are likely to influence our assessment of these interventions.

Early predictors of lumbar spine surgery after occupational back injury: results from a prospective study of workers in Washington State

STUDY DESIGN

Prospective population-based cohort study.

OBJECTIVE

To identify early predictors of lumbar spine surgery within 3 years after occupational back injury.

SUMMARY OF BACKGROUND DATA

Back injuries are the most prevalent occupational injury in the United States. Few prospective studies have examined early predictors of spine surgery after work-related back injury.

METHODS

Using Disability Risk Identification Study Cohort (D-RISC) data, we examined the early predictors of lumbar spine surgery within 3 years among Washington State workers, with new workers compensation temporary total disability claims for back injuries. Baseline measures included worker-reported measures obtained approximately 3 weeks after claim submission. We used medical bill data to determine whether participants underwent surgery, covered by the claim, within 3 years. Baseline predictors (P < 0.10) of surgery in bivariate analyses were included in a multivariate logistic regression model predicting lumbar spine surgery. The area under the receiver operating characteristic curve of the model was used to determine the model's ability to identify correctly workers who underwent surgery.

RESULTS

In the D-RISC sample of 1885 workers, 174 (9.2%) had a lumbar spine surgery within 3 years. Baseline variables associated with surgery (P < 0.05) in the multivariate model included higher Roland-Morris Disability Questionnaire scores, greater injury severity, and surgeon as first provider seen for the injury. Reduced odds of surgery were observed for those younger than 35 years, females, Hispanics, and those whose first provider was a chiropractor. Approximately 42.7% of workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who saw a chiropractor. The area under the receiver operating characteristic curve of the multivariate model was 0.93 (95% confidence interval, 0.92-0.95), indicating excellent ability to discriminate between workers who would versus would not have surgery.

CONCLUSION

Baseline variables in multiple domains predicted lumbar spine surgery. There was a very strong association between surgery and first provider seen for the injury even after adjustment for other important variables.

Design considerations of a randomized clinical trial on a cognitive behavioural intervention using communication and information technologies for managing chronic low back pain

Background

Psychological treatments have been successful in treating chronic low back pain (CLBP). However, the effect sizes are still modest and there is room for improvement. A way to progress is by enhancing treatment adherence and self-management using information and communication technologies (ICTs). Therefore, the objective of this study was to design a trial investigating the short- and long-term efficacy of cognitive behavioural treatment (CBT) for CLBP using or not ICTs. A secondary objective of this trial will be to evaluate the influence of relevant variables on treatment response. Possible barriers in the implementation of CBT with and without ICT will also be investigated.

Methods

A randomised controlled trial with 180 CLBP patients recruited from specialised care will be conducted. Participants will be randomly assigned to three conditions: Control group (CG), CBT, and CBT supported by ICTs (CBT + ICT). Participants belonging to the three conditions will receive a conventional rehabilitation program (back school). The CBT group program will last six sessions. The CBT + ICT group will use the internet and SMS to practice the therapeutic strategies between sessions and in the follow-ups at their homes. Primary outcome variables will be self-reported disability and pain intensity. Assessment will be carried out by blinded assessors in five moments: pre-treatment, post-treatment and 3-, 6-, and 12-month follow-ups. The influence of catastrophizing, fear-avoidance beliefs, anxiety and depression in response to treatment in the primary outcomes will also be analysed.

Discussion

This study will show data of the possible benefits of using ICTs in the improvement of CBT for treating CLBP.

Trial registration

ClinicalTrials.gov, NCT01802671

Pathophysiology, diagnosis, and treatment of discogenic low back pain

Discogenic low back pain is a serious medical and social problem, and accounts for 26%-42% of the patients with chronic low back pain. Recent studies found that the pathologic features of discs obtained from the patients with discogenic low back pain were the formation of the zones of vascularized granulation tissue, with extensive innervation in fissures extending from the outer part of the annulus into the nucleus pulposus. Studies suggested that the degeneration of the painful disc might originate from the injury and subsequent repair of annulus fibrosus. Growth factors such as basic fibroblast growth factor, transforming growth factor β1, and connective tissue growth factor, macrophages and mast cells might play a key role in the repair of the injured annulus fibrosus and subsequent disc degeneration. Although there exist controversies about the role of discography as a diagnostic test, provocation discography still is the only available means by which to identify a painful disc. A recent study has classified discogenic low back pain into two types that were annular disruption-induced low back pain and internal endplate disruption-induced low back pain, which have been fully supported by clinical and theoretical bases. Current treatment options for discogenic back pain range from medicinal anti-inflammation strategy to invasive procedures including spine fusion and recently spinal arthroplasty. However, these treatments are limited to relieving symptoms, with no attempt to restore the disc's structure. Recently, there has been a growing interest in developing strategies that aim to repair or regenerate the degenerated disc biologically.

Variation in outcomes across centers after surgery for lumbar stenosis and degenerative spondylolisthesis in the spine patient outcomes research trial

STUDY DESIGN

Retrospective review of a prospectively collected database.

OBJECTIVE

To examine whether short- and long-term outcomes after surgery for lumbar stenosis (SPS) and degenerative spondylolisthesis (DS) vary across centers.

SUMMARY OF BACKGROUND DATA

Surgery has been shown to be of benefit for both SPS and DS. For both conditions, surgery often consists of laminectomy with or without fusion. Potential differences in outcomes of these overlapping procedures across various surgical centers have not yet been investigated.

METHODS

Spine Patient Outcomes Research Trial cohort participants with a confirmed diagnosis of SPS or DS undergoing surgery were followed from baseline at 6 weeks, 3, 6, and 12 months, and yearly thereafter, at 13 spine clinics in 11 US states. Baseline characteristics and short- and long-term outcomes were analyzed.

RESULTS

A total of 793 patients underwent surgery. Significant differences were found between centers with regard to patient race, body mass index, treatment preference, neurological deficit, stenosis location, severity, and number of stenotic levels. Significant differences were also found in operative duration and blood loss, the incidence of durotomy, the length of hospital stay, and wound infection. When baseline differences were adjusted for, significant differences were still seen between centers in changes in patient functional outcome (Short Form-36 bodily pain and physical function, and Oswestry Disability Index) at 1 year after surgery. In addition, the cumulative adjusted change in the Oswestry Disability Index Score at 4 years significantly differed among centers, with Short Form-36 scores trending toward significance.

CONCLUSION

There is a broad and statistically significant variation in short- and long-term outcomes after surgery for SPS and DS across various academic centers, when statistically significant baseline differences are adjusted for. The findings suggest that the choice of center affects outcome after these procedures, although further studies are required to investigate which center characteristics are most important.

Lumbar spine fusion for chronic low back pain due to degenerative disc disease: a systematic review

STUDY DESIGN

Systematic literature review.

OBJECTIVE

To categorize published evidence systematically for lumbar fusion for chronic low back pain (LBP) in order to provide an updated and comprehensive analysis of the clinical outcomes.

SUMMARY OF BACKGROUND DATA

Despite a large number of publications of outcomes of spinal fusion surgery for chronic LBP, there is little consensus on efficacy.

METHODS

A MEDLINE and Cochrane database search was performed to identify published articles reporting on validated patient-reported clinical outcomes measures (2 or more of visual analogue scale, Oswestry Disability Index, Short Form [36] Health Survey [SF-36] PCS, and patient satisfaction) with minimum 12 months of follow-up after lumbar fusion surgery in adult patients with LBP due to degenerative disc disease. Twenty-six total articles were identified and stratified by level of evidence: 18 level 1 (6 studies of surgery vs. nonoperative treatment, 12 studies of alternative surgical procedures), 2 level 2, 2 level 3, and 4 level 4 (2 prospective, 2 retrospective). Weighted averages of each outcomes measure were computed and compared with established minimal clinically important difference values.

RESULTS

Fusion cohorts included a total of 3060 patients. The weighted average improvement in visual analogue scale back pain was 36.8/100 (standard deviation [SD], 14.8); in Oswestry Disability Index 22.2 (SD, 14.1); in SF-36 Physical Component Scale 12.5 (SD, 4.3). Patient satisfaction averaged 71.1% (SD, 5.2%) across studies. Radiographical fusion rates averaged 89.1% (SD, 13.5%), and reoperation rates 12.5% (SD, 12.4%) overall, 9.2% (SD, 7.5%) at the index level. The results of the collective studies did not differ statistically in any of the outcome measures based on level of evidence (analysis of variance, P > 0.05).

CONCLUSION

The body of literature supports fusion surgery as a viable treatment option for reducing pain and improving function in patients with chronic LBP refractory to nonsurgical care when a diagnosis of disc degeneration can be made.

Trends in orthopedics: an analysis of Medicare claims, 2000-2010

The complete Medicare Part B claims databases for the years 2000 through 2010 were queried. Musculoskeletal procedures were grouped into 12 anatomical or functional groups for multiyear analysis. Utilization rates per 1000 Medicare beneficiaries and spending per Medicare beneficiary were calculated. Compound annual growth rates were used to compare spending trends with national health care spending data. Medicare payments for orthopedic procedures increased 63.7% in 10 years, from $1.6 billion in 2000 to $2.6 billion in 2010. The number of procedures increased by a similar proportion, from 8.2 to 13.6 million (66.9%); the average reimbursement per procedure decreased slightly. The overall utilization rate increased by 41.4% over the past decade, from 206.73 to 292.41 per 1000 beneficiaries. Considerable variation was found when these procedures were analyzed, with utilization rates per 1000 beneficiaries ranging from large increases (spine, +214.5%; endoscopy, +128%) to modest decreases (hand and fingers, -9.9%). Payment trends, corrected for inflation and growth in the number of Medicare enrollees, showed similar heterogeneity. Payment per beneficiary increased at only 0.65% above inflation for orthopedic procedures, well below the 4.67% compound annual growth rate seen for overall Medicare spending.These data demonstrate that, despite significant increases in its utilization, orthopedics does not appear to be a driver for increases in Medicare spending over the past decade. Only spinal and endoscopic procedures stand out as having experienced exceptional growth; demonstration of clinical success and cost effectiveness in these areas would be helpful to strengthen support for these evolving trends in orthopedic practice.

Exploring the care experience of patients undergoing spinal surgery: a qualitative study

PURPOSE

This exploratory study sought to explore the patient experience of the surgical journey from decision to operate, to hospitalization, discharge and subsequent recovery.

DESIGN

Patients attended one of two focus group discussions.

PATIENT SAMPLE

Seven patients that had undergone surgery for spinal stenosis or disc prolapsed participated, aged between 48-75 years (mean age 59); five were male.

METHODS

Patients' attitudes towards the information and care they received from the point of the decision to operate through to post-operative recovery were explored. Particular attention was paid to patients' information needs, support provided, general understanding of the processes and ways in which care could have been improved.

RESULTS

Patients identified nine main 'needs' they felt played an integral part in enhancing the patient experience including the need for reduced waiting times, for better information and preparation, to be proactive, to speak up and ask questions, to feel safe and to be treated with dignity and respect; and the need for ongoing support, human contact, and; continuity of care.

CONCLUSION

These findings suggest that there are several measures that could be taken to improve the patient's surgical experience. In particular, providing appropriate information to patients in a timely manner and ensuring that support and advice is easily accessible for those patients that need it are key areas for improvement.

The effect of required physiatrist consultation on surgery rates for back pain

STUDY DESIGN

Prospective trial with insurance database and surveys.

OBJECTIVE

This study was developed to determine whether an insurer rule requiring physiatrist consultation before nonurgent surgical consultation would affect surgery referrals and surgery rates.

SUMMARY OF BACKGROUND DATA

Spine surgery rates are highly variable by region and increasing without evidence of a concordant decrease in the burden of disease. Efforts to curb misuse of surgery have not shown large changes, especially across different provider groups. As nonsurgical spine experts, physiatrists might provide patients with a different perspective on treatment options.

METHODS

In 2007, the insurer required patients with nonurgent spine surgical consultations in a geographic region to first have a single visit with a physiatrist, who received extra compensation for the assessment. Surgical consultation and surgical rates results were compared between 2006-2007 and 2008-2010. An automated telephone survey of patients evaluated by physiatrists was performed to assess patient satisfaction.

RESULTS

Physiatry referrals increased 70%, surgical referrals decreased 48%, and the total number of spine operations dropped 25%, with concomitant decreased overall cost. Although spinal fusion rates dropped, the percentage of fusion operations increased from 55% to 63% of all surgical procedures. Of 740 patients surveyed (48% response rate), 74% were satisfied or very satisfied with the physiatry consultation. Only 40% of patients who underwent previous spine surgery were satisfied. Although surgical rates decreased at all regional hospitals and all surgical groups, there were substantial shifts in market share.

CONCLUSION

Mandatory physiatrist consultation prior to surgical consultation resulted in decreased surgical rates and continued patient satisfaction across a large region.

Comparison of chronic occupational upper extremity versus lumbar disorders for differential disability-related outcomes and predictor variables

OBJECTIVE

To systematically evaluate if an interdisciplinary functional restoration program (FRP), shown to be a viable treatment option for patients with chronic disabling occupational lumbar disorders, is as effective in treating chronic disabling occupational upper extremity disorders.

METHODS

Participants were 2484 consecutive patients with either arm or lumbar disorders admitted to an FRP. Analyses compared demographic, psychosocial, and work-related factors, and 1-year post-rehabilitation socioeconomic outcomes.

RESULTS

Socioeconomic outcomes showed that work-return and work-retention rates after successful completion of the FRP did not differ between the two groups, or among the upper extremity subgroups.

CONCLUSIONS

FRP is equally effective for patients with chronic upper extremity or lumbar spine disorders, regardless of the injury type, site in the upper extremity, or the disparity in injury-specific and psychosocial factors identified before treatment.

Risk of lumbar spine injury from cyclic compressive loading

STUDY DESIGN

Survival analyses of a large cohort of published lumbar spine compression fatigue tests.

OBJECTIVE

To produce the first large-scale evaluation of human lumbar spine tolerance to repetitive compressive loading and to evaluate and improve guidelines for human exposure to whole-body vibration and repeated mechanical shock environments.

SUMMARY OF BACKGROUND DATA

Several studies have examined the effects of compressive cyclic loading on the lumbar spine. However, no previous effort has coalesced these studies and produced an injury risk analysis with an expanded sample size. Guidelines have been developed for exposure limits to repetitive loading (e.g., ISO 2631-5), but there has been no large-scale verification of the standard against experimental data.

METHODS

Survival analyses were performed using the results of 77 male and 28 female cadaveric spinal segment fatigue tests from 6 previously published studies. Segments were fixed at each end and exposed to axial cyclic compression. The effects of the number of cycles, load amplitude, sex, and age were examined through the use of survival analyses.

RESULTS

Number of cycles, load amplitude, sex, and age all are significant factors in the likelihood of bony failure in the spinal column. Using a modification of the risk prediction parameter from ISO 2631-5, an injury risk model was developed, which relates risk of vertebral failure to repeated compressive loading. The model predicts lifetime risks less than 7% for industrial machinery exposure from axial compression alone. There was a 38% risk for a high-speed planing craft operator, consistent with epidemiological evidence.

CONCLUSION

A spinal fatigue model which predicts the risk of in vitro lumbar spinal failure within a narrow confidence interval has been developed. Age and sex were found to have significant effects on fatigue strength, with sex differences extending beyond those accounted for by endplate area disparities.

Spinal fusion in the treatment of chronic low back pain: rationale for improvement

Results following fusion for chronic low back pain (CLBP) are unpredictable and generally not very satisfying. The major reason is the absence of a detailed description of the symptoms of patients with pain, if present, in a motion segment of the spine. Various radiological findings have been attributed to discogenic pain, but if these radiological signs were really true signs of such pain, fusion would have been very successful. If discogenic pain exists, it should be possible to select these patients from all others within the CLBP population. Even if this selection were 100% perfect, however, identification of the painful segment would remain, and at present there is no reliable test for doing so. Regardless of whether an anterior or posterior type of fusion is performed, or even if artificial discs are used, solving the puzzle of pain associated with the presumed segmental disorder must be the primary goal.

Predicting the evolution of low back pain patients in routine clinical practice: results from a registry within the Spanish National Health Service

BACKGROUND CONTEXT

The Spanish National Health Service (SNHS) is a tax-funded public organization that provides free health care to every resident in Spain.

PURPOSE

To develop models for predicting the evolution of low back pain (LBP) in routine clinical practice within SNHS.

STUDY DESIGN

Analysis of a prospective registry in routine clinical practice, in 17 centers across SNHS.

PATIENT SAMPLE

Patient sample includes 4,477 acute and chronic LBP patients treated in primary and hospital care.

OUTCOME MEASURES

Pain and disability, measured through validated instruments.

METHODS

Patients treated for LBP were assessed at baseline and 3 months later. Data gathered were the following: sex, age, employment status, duration of pain, severity of LBP, pain down to the leg (LP) and disability, history of lumbar surgery, diagnostic procedures undertaken, imaging findings, and treatments used throughout the study period. Three separate multivariate logistic regression models were developed for predicting a clinically relevant improvement in LBP, LP, and disability at 3 months.

RESULTS

In total, 4,261 patients (95.2%) attended follow-up. For all the models, calibration was reasonable and the area under the receiver operating characteristic curve was ≥0.640. For LBP, LP, and disability, factors associated with a higher probability of improvement at 3 months were the following: not having undergone lumbar surgery, higher baseline scores for the corresponding variable, lower ones for the rest, and being treated with neuroreflexotherapy. Additional factors were the following: for LBP, shorter pain duration; for LP, not undergoing electromyography; and for disability, shorter pain duration, not being diagnosed with disc degeneration, and being treated with muscle relaxants and not opioids.

CONCLUSIONS

A prospective registry can be used for developing predictive models to quantify the odds that a given LBP patient will experience a clinically relevant improvement. This may empower patients for an informed shared decision making.

Sevoflurane versus propofol anesthesia in patients undergoing lumbar spondylodesis: a randomized trial

BACKGROUND

Spondylodesis is a procedure aiming at providing stability in one or more spinal segments. The aim of our study was to compare sevoflurane and propofol as induction and maintenance agents, focusing on hemodynamic stability, recovery characteristics, postoperative nausea and vomiting, and pain intensity.

MATERIALS AND METHODS

Seventy patients, with a physical status according to American Society of Anesthesiologists (ASA) I-II, 50-72 y old, undergoing selective lumbar spondylodesis were enrolled.

RESULTS

There was no statistically significant difference between groups in overall mean hemodynamic parameters. No differences in fluid administration and vasoactive substances used were noted. Postoperatively, there was a significant difference in overall mean visual analog score at rest and at cough, with the sevoflurane group showing lower values. No differences in the incidence of nausea, vomiting, shivering, postoperative sedation scores, and orientation to place were revealed. Orientation to time exhibited a statistically significant difference at the time just after transfer to the post-anesthesia care unit, where more patients of the sevoflurane group seemed to be well oriented.

CONCLUSIONS

Sevoflurane and propofol anesthesia for lumbar spondylodesis surgery provide safe and comparable results.

Prognostic factors for non-success in patients with sciatica and disc herniation

BACKGROUND

Few studies have investigated prognostic factors for patients with sciatica, especially for patients treated without surgery. The aim of this study was to identify factors associated with non-success after 1 and 2 years of follow-up and to test the prognostic value of surgical treatment for sciatica.

METHODS

The study was a prospective multicentre observational study including 466 patients with sciatica and lumbar disc herniation. Potential prognostic factors were sociodemographic characteristics, back pain history, kinesiophobia, emotional distress, pain, comorbidity and clinical examination findings. Study participation did not alter treatment considerations for the patients in the clinics. Patients reported on the questionnaires if surgery of the disc herniation had been performed. Uni- and multivariate logistic regression analyses were used to evaluate factors associated with non-success, defined as Maine-Seattle Back Questionnaire score of ≥5 (0-12) (primary outcome) and Sciatica Bothersomeness Index ≥7 (0-24) (secondary outcome).

RESULTS

Rates of non-success were at 1 and 2 years 44% and 39% for the main outcome and 47% and 42% for the secondary outcome. Approximately 1/3 of the patients were treated surgically. For the main outcome variable, in the final multivariate model non-success at 1 year was significantly associated with being male (OR 1.70 [95% CI; 1.06 - 2.73]), smoker (2.06 [1.31 - 3.25]), more back pain (1.0 [1.01 - 1.02]), more comorbid subjective health complaints (1.09 [1.03 - 1.15]), reduced tendon reflex (1.62 [1.03 - 2.56]), and not treated surgically (2.97 [1.75 - 5.04]). Further, factors significantly associated with non-success at 2 years were duration of back problems >; 1 year (1.92 [1.11 - 3.32]), duration of sciatica >; 3 months (2.30 [1.40 - 3.80]), more comorbid subjective health complaints (1.10 [1.03 - 1.17]) and kinesiophobia (1.04 [1.00 - 1.08]). For the secondary outcome variable, in the final multivariate model, more comorbid subjective health complaints, more back pain, muscular weakness at clinical examination, and not treated surgically, were independent prognostic factors for non-success at both 1 and 2 years.

CONCLUSIONS

The results indicate that the prognosis for sciatica referred to secondary care is not that good and only slightly better after surgery and that comorbidity should be assessed in patients with sciatica. This calls for a broader assessment of patients with sciatica than the traditional clinical assessment in which mainly the physical symptoms and signs are investigated.

Guiding low back claimants to work: a randomized controlled trial

STUDY DESIGN

A single-blinded, randomized controlled trial.

OBJECTIVE

To determine the impact of information and advice during a disability evaluation by medical advisers on the return to work (RTW) rate and recurrence of sick leave of claimants with low back pain (LBP).

SUMMARY OF BACKGROUND DATA

There is evidence on the importance of advice during the course of subacute LBP. The effect of informative interventions on RTW rates in workers receiving sickness benefit is not clear.

METHODS

A total of 506 claimants with LBP were randomly assigned to the control group (disability evaluation) or the intervention group (combined counseling and disability evaluation). RTW, sick leave recurrence, subsequent surgery, and sick leave duration were measured during a 12-month follow-up.

RESULTS

Patients who were provided information and advice showed a higher RTW rate, which was statistically significant at 1 year. That result is mainly attributable to the lower relapse rate in the intervention group (38%) than in the control group (60%). There were no differences between the 2 groups regarding subsequent surgery for LBP and duration of sick leave.

CONCLUSION

Claimants should be routinely reassured and advised about LBP to allow early and safe RTW during a disability evaluation before any side effects of being sick-listed have settled.

A decade's experience in lumbar spine surgery in Belgium: sickness fund beneficiaries, 2000-2009

PURPOSE

The purpose is to study rates, trends, geographic variations and outcome of lumbar spine surgery in the Belgian population during the last decade.

METHODS

This is a retrospective cohort study using administrative data of the largest Belgian sickness fund from January 1, 2000 through December 31, 2009. Cases included lumbar laminectomy, combined discectomy and fusion, posterior interarticular fusion, anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF) and standard discectomy. The main outcome measures were age- and sex-adjusted rates of lumbar spine surgery, 1-year mortality, 1-year iterative surgery, no return to work (RTW) rate 1 year after surgery and length of hospital stay. Multivariate logistic regression analysis was used to determine the association between age, sex, geographic region, type of surgery, year of intervention and duration of pre-operative sick leave on outcome.

RESULTS

Spine surgery rates rose 44 % from 2001 through 2009 and data for 2009 showed twofold variations in spine surgery rates among 10 Belgian provinces. Reported 1-year mortality varied from 0.6 to 2.5 % among surgical procedures performed in 2008. The overall 5-year reoperation rate was 12 %. RTW rates 1 year after standard discectomy, ALIF, PLIF and combined discectomy and fusion for the follow-up sample of 2008 were 14.4, 22.7, 26.1 and 30.6 %, respectively. The median length of hospital stay significantly decreased throughout the decade. Type of surgery and geographic region were significantly related to patient outcomes.

CONCLUSIONS

Regional variations highlight professional uncertainty and controversy. The study results point to the need for peer comparisons and surgeon feedback.

Role of lumbar interspinous distraction on the neural elements

The interspinous distraction devices are used to treat variable pathologies ranging from facet syndrome, diskogenic low back pain, degenerative spinal stenosis, diskopathy, spondylolisthesis, and instability. The insertion of a posterior element with an interspinous device (ISD) is commonly judged responsive to a relative kyphosis of a lumbar segment with a moderate but persistent increase of the spinal canal and of the foraminal width and area, and without influence on low-grade spondylolisthesis. The consequence is the need of shared specific biomechanical concepts to give for each degenerative problem the right indication through a critical analysis of all available experimental and clinical biomechanical data. We reviewed systematically the available clinical and experimental data about kyphosis, enlargement of the spinal canal, distraction of the interspinous distance, increase of the neural foramina, ligamentous structures, load of the posterior annulus, intradiskal pressure, strength of the spinous processes, degeneration of the adjacent segment, complications, and cost-effectiveness of the ISD. The existing literature does not provide actual scientific evidence over the superiority of the ISD strategy, but most of the experimental and clinical data show a challenging potential. These considerations are applicable with different types of ISD with only few differences between the different categories. Despite--or because of--the low invasiveness of the surgical implantation of the ISD, this technique promises to play a major role in the future degenerative lumbar microsurgery. The main indications for ISD remain lumbar spinal stenoses and painful facet arthroses. A clear documented contraindication is the presence of an anterolisthesis. Nevertheless, the existing literature does not provide evidence of superiority of outcome and cost-effectiveness of the ISD strategy over laminectomy or other surgical procedures. At this time, the devices should be used in clinical randomized independent trials in order to obtain more information concerning the most advantageous optimal indication or, in selected cases, to treat tailored indications.

Nonoperative treatment of lumbar spinal stenosis with neurogenic claudication: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVE

To systematically review the evidence for the effectiveness of nonoperative treatment of lumbar spinal stenosis with neurogenic claudication.

SUMMARY OF BACKGROUND DATA

Neurogenic claudication can significantly impact functional ability, quality of life, and independence in the elderly. METHODS.: We searched CENTRAL, MEDLINE, EMBASE, CINAHL, and ICL databases up to January 2011 for randomized controlled trials published in English, in which at least 1 arm provided data on nonoperative treatments. Risk of bias in each study was independently assessed by 2 reviewers using 12 criteria. Quality of the evidence was evaluated using Grades of Recommendations, Assessment, Development, and Evaluation (GRADE).

RESULTS

From the 8635 citations screened, 56 were assessed and 21 trials with 1851 participants were selected. There is very low-quality evidence from 6 trials that calcitonin is no better than placebo or paracetamol, regardless of mode of administration or outcome. From single small trials, there is low-quality evidence that prostaglandins, and very low-quality evidence that gabapentin or methylcobalamin, improve walking distance. There is very low-quality evidence from a single trial that epidural steroid injections improve pain, function, and quality of life up to 2 weeks compared with home exercise or inpatient physical therapy. There is low-quality evidence from a single trial that exercise is of short-term benefit for leg pain and function compared with no treatment. There is low- and very low-quality evidence from 6 trials that multimodal nonoperative treatment is less effective than indirect or direct surgical decompression with or without fusion.

CONCLUSION

Moderate- and high-GRADE evidence for nonoperative treatment is lacking and thus prohibiting recommendations to guide clinical practice. Given the expected exponential rise in the prevalence of lumbar spinal stenosis with neurogenic claudication, large high-quality trials are urgently needed.

Lateral interbody fusion for treatment of discogenic low back pain: minimally invasive surgical techniques

Low back pain is one of the most common ailments in the general population, which tends to increase in severity along with aging. While few patients have severe enough symptoms or underlying pathology to warrant surgical intervention, in those select cases treatment choices remain controversial and reimbursement is a substancial barrier to surgery. The object of this study was to examine outcomes of discogenic back pain without radiculopathy following minimally-invasive lateral interbody fusion. Twenty-two patients were treated at either one or two levels (28 total) between L2 and 5. Discectomy and interbody fusion were performed using a minimallyinvasive retroperitoneal lateral transpsoas approach. Clinical and radiographic parameters were analyzed at standard pre- and postoperative intervals up to 24 months. Mean surgical duration was 72.1 minutes. Three patients underwent supplemental percutaneous pedicle screw instrumentation. Four (14.3%) stand-alone levels experienced cage subsidence. Pain (VAS) and disability (ODI) improved markedly postoperatively and were maintained through 24 months. Segmental lordosis increased significantly and fusion was achieved in 93% of levels. In this series, isolated axial low back pain arising from degenerative disc disease was treated with minimally-invasive lateral interbody fusion in significant radiographic and clinical improvements, which were maintained through 24 months.

Disparities in rates of spine surgery for degenerative spine disease between HIV-infected and uninfected veterans

STUDY DESIGN

Retrospective analysis of nationwide Veterans Health Administration clinical and administrative data.

OBJECTIVE

Examine the association between HIV infection and the rate of spine surgery for degenerative spine disease.

SUMMARY OF BACKGROUND DATA

Combination antiretroviral therapy has prolonged survival in HIV-infected patients, increasing the prevalence of chronic conditions such as degenerative spine disease that may require spine surgery.

METHODS

We studied all HIV-infected patients under care in the Veterans Health Administration from 1996 to 2008 (n = 40,038) and uninfected comparator patients (n = 79,039) matched on age, sex, race, year, and geographic region. The primary outcome was spine surgery for degenerative spine disease, defined by International Classification of Diseases, Ninth Revision procedure and diagnosis codes. We used a multivariate Poisson regression to model spine surgery rates by HIV infection status, adjusting for factors that might affect suitability for surgery (demographics, year, comorbidities, body mass index, combination antiretroviral therapy, and laboratory values).

RESULTS

Two hundred twenty-eight HIV-infected and 784 uninfected patients underwent spine surgery for degenerative spine disease during 700,731 patient-years of follow-up (1.44 surgeries per 1000 patient-years). The most common procedures were spinal decompression (50%) and decompression and fusion (33%); the most common surgical sites were the lumbosacral (50%) and cervical (40%) spine. Adjusted rates of surgery were lower for HIV-infected patients (0.86 per 1000 patient-years of follow-up) than for uninfected patients (1.41 per 1000 patient-years; incidence rate ratio 0.61, 95% confidence interval: 0.51-0.74, P < 0.001). Among HIV-infected patients, there was a trend toward lower rates of spine surgery in patients with detectable viral load levels (incidence rate ratio 0.76, 95% confidence interval: 0.55-1.05, P = 0.099).

CONCLUSION

In the Veterans Health Administration, HIV-infected patients experience significantly reduced rates of surgery for degenerative spine disease. Possible explanations include disease prevalence, emphasis on treatment of nonspine HIV-related symptoms, surgical referral patterns, impact of HIV on surgery risk-benefit ratio, patient preferences, and surgeon bias.

Effect of methodological quality measures in spinal surgery research: a metaepidemiological study

BACKGROUND CONTEXT

Methodological quality measures of trials in meta-analyses have been shown to influence the pooled effect sizes in several medical fields. However, for spinal surgery, influence of quality measures has not been assessed.

PURPOSE

The purpose of this study was to analyze the influence of quality measures in studies on effectiveness in spinal surgery.

STUDY DESIGN

A metaepidemiological study was performed on meta-analyses within spinal surgery.

METHODS

A systematic search was performed in MEDLINE, Cochrane Database, and EMBASE in August 2009. The effect sizes, defined as risk of positive clinical outcome, of trials included in the meta-analyses were assessed. The differences in effect sizes were calculated as risk differences (RDs). Relation of the RDs to potential quality measures such as sponsoring, randomization, allocation concealment, blinding, and study size was assessed with metaregression adjusted for multiple testing.

RESULTS

Seven reviews consisting of 118 studies were included. Data provided by the systematic reviews alone were insufficient to analyze the effect of quality measures. Metaregression analysis of 76 of the individual trials reporting clinical outcome, though, showed that sample size, strict randomization, and outcome blinding were significant quality measures influencing study effect. Risk difference of effect from validly randomized studies was higher compared with not validly randomized and comparative observational trials (5.4%; 95% confidence interval [CI], 1.2-9.6; p=.044). Studies with adequate observer blinding showed a 7.2% lower RD (95% CI, 0.8-13.7; p=.049). For each increase of 100 patients, the RD decreased 3.6% (95% CI, 0.5-6.8; p=.098).

CONCLUSIONS

Contrary to basic methodological assertions, formal and strict randomization appeared to produce a significantly higher RD in spinal surgery research. Sufficient sample size and observer blinding, on the other hand, led to a lower RD as expected. These findings imply that effect of quality measures assessed in metaepidemiological studies should not be too easily translated to research in spinal surgery.

[Chronic lower back pain]

Poor efficiency in terms of treatment of unspecific back pain and related chronic pain syndromes has led to the necessity of general care guidelines addressing evidence-based strategies for treatment of lower back pain (LBP). Systematically validated and reviewed algorithms have been established for all kinds of unspecific back pain, covering both acute and chronic syndromes. Concerning the impact of psychosocial risk factors in the development of chronic LBP, multimodal treatment is preferred to monomodal strategies. Self-responsible acting on the part of the patient should be supported while invasive methods in particular, i.e. operative treatment, should be avoided due to lacking evidence in outcome efficiency.

Interspinous spacer implant in patients with lumbar spinal stenosis: preliminary results of a multicenter, randomized, controlled trial

A prospective, randomized, controlled trial was conducted to compare clinical outcomes in patients treated with an investigational interspinous spacer (Superion) versus those treated with an FDA-approved spacer (X-STOP). One hundred sixty-six patients with moderate lumbar spinal stenosis (LSS) unresponsive to conservative care were treated randomly with the Superion (n = 80) or X-STOP (n = 86) interspinous spacer. Study subjects were followed through 6 months posttreatment. Zurich Claudication Questionnaire (ZCQ) symptom severity scores improved 30% with Superion and 25% with X-STOP (both P < 0.001). Similar changes were noted in ZCQ physical function with improvements of 32% with Superion and 27% with X-STOP (both P < 0.001). Mean ZCQ patient satisfaction score ranged from 1.7 to 2.0 in both groups at all follow-up visits. The proportion of subjects that achieved at least two of three ZCQ clinical success criteria at 6 months was 75% with Superion and 67% with X-STOP. Axial pain decreased from 55 ± 27 mm at pretreatment to 22 ± 26 mm at 6 months in the Superion group (P < 0.001) and from 54 ± 29 mm to 32 ± 31 mm with X-STOP (P < 0.001). Extremity pain decreased from 61 ± 26 mm at pretreatment to 18 ± 27 mm at 6 months in the Superion group (P < 0.001) and from 64 ± 26 mm to 22 ± 30 mm with X-STOP (P < 0.001). Back function improved from 38 ± 13% to 21 ± 19% with Superion (P < 0.001) and from 40 ± 13% to 25 ± 16% with X-STOP (P < 0.001). Preliminary results suggest that the Superion interspinous spacer and the X-STOP each effectively alleviate pain and improve back function in patients with moderate LSS who are unresponsive to conservative care.

Repeat surgery after lumbar decompression for herniated disc: the quality implications of hospital and surgeon variation

BACKGROUND CONTEXT

Repeat lumbar spine surgery is generally an undesirable outcome. Variation in repeat surgery rates may be because of patient characteristics, disease severity, or hospital- and surgeon-related factors. However, little is known about population-level variation in reoperation rates.

PURPOSE

To examine hospital- and surgeon-level variation in reoperation rates after lumbar herniated disc surgery and to relate these to published benchmarks.

STUDY DESIGN/SETTING

Retrospective analysis of a discharge registry including all nonfederal hospitals in Washington State.

METHODS

We identified adults who underwent an initial inpatient lumbar decompression for herniated disc from 1997 to 2007. We then performed generalized linear mixed-effect logistic regressions, controlling for patient characteristics and comorbidity, to examine the variation in reoperation rates within 90 days, 1 year, and 4 years.

RESULTS

Our cohort included 29,529 patients with a mean age of 47.5 years, 61% privately insured, and 15% having any comorbidity. The age-, sex-, insurance-, and comorbidity-adjusted mean rate of reoperation among hospitals was 1.9% at 90 days (95% confidence interval [CI], 1.2-3.1), with a range from 1.1% to 3.4%; 6.4% at 1 year (95% CI, 3.9-10.6), with a range from 2.8% to 12.5%; and 13.8% at 4 years (95% CI, 8.8-19.8), with a range from 8.1% to 24.5%. The adjusted mean reoperation rates of surgeons were 1.9% at 90 days (95% CI, 1.4-2.4) with a range from 1.2% to 4.6%, 6.1% at 1 year (95% CI, 4.8-7.7) with a range from 4.3% to 10.5%, and 13.2% at 4 years (95% CI, 11.3-15.5) with a range from 10.0% to 19.3%. Multilevel random-effect models suggested that variation across surgeons was greater than that of hospitals and that this effect increased with long-term outcomes.

CONCLUSIONS

Even after adjusting for patient demographics and comorbidity, we observed a large variation in reoperation rates across hospitals and surgeons after lumbar discectomy, a relatively simple spinal procedure. These findings suggest uncertainty about indications for repeat surgery, variations in perioperative care, or variations in quality of care.

Postoperative improvement in health-related quality of life: a national comparison of surgical treatment for focal (one- to two-level) lumbar spinal stenosis compared with total joint arthroplasty for osteoarthritis

BACKGROUND CONTEXT

The results of single-center studies have shown that surgical intervention for lumbar spinal stenosis yielded comparable health-related quality of life (HRQoL) improvement to total joint arthroplasty (TJA). Whether these results are generalizable to routine clinical practice in Canada is unknown.

PURPOSE

The primary purpose of this equivalence study was to compare the relative improvement in physical HRQoL after surgery for focal lumbar spinal stenosis (FLSS) compared with TJA for hip and knee osteoarthritis (OA) across six Canadian centers.

STUDY DESIGN/SETTING

A Canadian multicenter ambispective cohort study.

PATIENT SAMPLE

A cohort of 371 primary one- to two-level spinal decompression (n=214 with instrumented fusion) for FLSS (n=179 with degenerative lumbar spondylolisthesis [DLS]) was compared with a cohort of primary total hip (n=156) and knee (n=208) arthroplasty for OA.

OUTCOME MEASURES

The primary outcome was the change in preoperative to 2-year postoperative 36-Item Short Form Health Survey Physical Component Summary (PCS) score as reflected by the number of patients reaching minimal clinically important difference (MCID) and substantial clinical benefit (SCB).

METHODS

Univariate analyses were conducted to identify baseline differences and factors that were significantly related to outcomes at 2 years. Multivariable regression modeling was used as our primary analysis to compare outcomes between groups.

RESULTS

The mean age (years) and percent females for the spine, hip, and knee groups were 63.3/58.5, 66.0/46.9, and 65.8/64.3, respectively. All three groups experienced significant improvement of baseline PCS (p<.001). Multivariate analyses, adjusting for baseline differences (age, gender, baseline Mental Component Summary score, baseline PCS), demonstrated no significant differences in PCS outcome between spinal surgery and arthroplasty (combined hip and knee cohorts) patients with an odds ratio of 0.80 (95% confidence interval [CI], 0.57-1.11; p=.17) and 0.79 (95% CI, 0.58-1.09; p=.15) for achieving MCID or SCB, respectively. In subgroup analysis, spine and knee outcomes were not significantly different, with hip arthroplasty superior to both (p<.0001).

CONCLUSIONS

Significant improvement in physical HRQoL after surgical treatment of FLSS (including DLS) is consistently achieved nationally. Our overall results demonstrate that a comparable number of patients can expect to achieve MCID and SCB 2 years after surgical intervention for FLSS and total knee arthroplasty.

Minimally invasive treatment of moderate lumbar spinal stenosis with the superion interspinous spacer

PURPOSE

We evaluated the safety and effectiveness of the minimally invasive Superion(®) Interspinous Spacer (VertiFlex, Inc., San Clemente, CA) in patients with moderate LSS.

METHODS

This single-arm prospective study enrolled 121 patients with moderate LSS between February 2008 and August 2009 and were followed up at 1 (n=111), 3 (n=96), 6 (n=81), and 12 (n=52) months. All patients were treated with the Superion Interspinous Spacer. Main outcomes were back function with the Oswestry Disability Index (ODI), extremity and axial pain severity with an 11-point scale, health-related quality of life with the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores from the SF-36, and adverse events through 12 months.

RESULTS

ODI improved 64% (p<0.001) through 12 months and clinical success was 92%. Extremity and axial pain improved 53% and 49% (both p<0.001), respectively, through 12 months with clinical success of 76% for axial pain and 86% for extremity pain. Health-related quality of life improved 41% for PCS and 22% for MCS (both p<0.001) through 12 months. PCS clinical success was 81% and MCS clinical success was 62% at 12 months. Four (5.9%) explants were performed although 3 were unrelated to the device. Eight procedure-related adverse events, observed in 6 (5.0%) patients, included superficial incision seroma (n=5), minor wound pain (n=2), and infection (n=1).

CONCLUSIONS

Preliminary results with the Superion Interspinous Spacer suggest that it is an effective and safe treatment option for patients with moderate LSS who are unresponsive to conservative care.

ISSLS prize winner: Function After Spinal Treatment, Exercise, and Rehabilitation (FASTER): a factorial randomized trial to determine whether the functional outcome of spinal surgery can be improved

STUDY DESIGN

This was a multicenter, factorial, randomized, controlled trial on the postoperative management of spinal surgery patients, with randomization stratified by surgeon and operative procedure.

OBJECTIVE

This study sought to determine whether the functional outcome of two common spinal operations could be improved by a program of postoperative rehabilitation that combines professional support and advice with graded active exercise commencing 6 weeks after surgery and/or an educational booklet based on evidence-based messages and advice received at discharge from hospital, each compared with usual care.

SUMMARY OF BACKGROUND DATA

Surgical interventions on the spine are increasing, and while surgery for spinal stenosis and disc prolapse have been shown to be superior to conservative management, functional outcome, and patient satisfaction are not optimal.

METHODS

The study compared the effectiveness of a rehabilitation program and an education booklet for the postoperative management of patients undergoing discectomy or lateral nerve root decompression surgery, each compared with "usual care" using a 2 × 2 factorial design, randomizing patient to four groups; rehabilitation-only, booklet-only, rehabilitation-plus-booklet, and usual care only. The primary outcome measure was the Oswestry Disability Index (ODI) at 12 months, with secondary outcomes including visual analog scale measures of back and leg pain.

RESULTS

Three hundred thirty-eight patients were recruited into the study and measurements were obtained preoperatively and then repeated at 6 weeks, 3, 6, 9 and 12 months postoperatively. Twelve months postoperatively the observed effect of rehabilitation on ODI was -2.7 (95% CI: -6.8 to 1.5) and the effect of booklet was 2.7 (95% CI: -1.5 to 6.9).

CONCLUSION

This study found that neither intervention had a significant impact on long-term outcome.

Diagnostic pitfalls in spine surgery: masqueraders of surgical spine disease

Disorders of the spine are common in clinical medicine, and spine surgery is being performed with increasing frequency in the US. Although many patients with an established diagnosis of a true surgically treatable lesion are referred to a neurosurgeon, the evaluation of patients with spinal disorders can be complex and fraught with diagnostic pitfalls. While “common conditions are common,” astute clinical acumen and vigilance are necessary to identify lesions that masquerade as surgically treatable spine disease that can lead to erroneous diagnosis and treatment. In this review, the authors discuss musculoskeletal, peripheral nerve, metabolic, infectious, inflammatory, and vascular conditions that mimic the syndromes produced by surgical lesions. It is possible that nonsurgical and surgical conditions coexist at times, complicating treatment plans and natural histories. Awareness of these diagnoses can help reduce diagnostic error, thereby avoiding the morbidity and expense associated with an unnecessary operation.

Management of degenerative disk disease and chronic low back pain

Degenerative disk disease is a strong etiologic risk factor of chronic low back pain (LBP). A multidisciplinary approach to treatment is often warranted. Patient education, medication, and cognitive behavioral therapies are essential in the treatment of chronic LBP sufferers. Surgical intervention with a rehabilitation regime is sometimes advocated. Prognostic factors related to the outcome of different treatments include maladaptive pain coping and genetics. The identification of pain genes may assist in determining individuals susceptible to pain and in patient selection for appropriate therapy. Biologic therapies show promise, but clinical trials are needed before advocating their use in humans.